Several polls have indicated that health care will be a top issue for Americans in their choice of nominee for the 2020 presidential election.1 While the Affordable Care Act (ACA) has dramatically cut the number of Americans without health insurance, reduced consumers’ overall out-of-pocket spending, and ensured that people with preexisting health conditions can get the coverage they need, significant problems remain: about 30 million people remain uninsured, an estimated 44 million are underinsured, and health care costs are growing faster than median income in most states.2
Several of the Democratic candidates have proposed health reform plans aimed at addressing these problems. Their proposals range from building on the ACA’s coverage expansions, such as providing more generous subsidies for those purchasing coverage, to creating a public plan option or reorganizing the health system to make a public plan like Medicare the nation’s primary source of coverage.
The Commonwealth Fund’s new Health Insurance in America Survey provides the latest information on the state of health insurance coverage for working-age adults, their coverage experiences and views, and their views of current health policy proposals. To conduct the survey, the survey research firm SSRS interviewed a nationally representative sample of 4,914 adults ages 19 to 64 from March 19 through June 9, 2019. Seventy percent of respondents completed the questionnaire by landline or cell phone, while 30 percent completed it online after being contacted by mail. (This approach represents a significant change from the previous sampling methodology used for the survey and affected trends in responses to certain questions. See “How We Conducted This Study” for more detail.)
- 13.8 percent of U.S. working-age adults are uninsured, down from 19.9 percent just prior to the ACA’s coverage expansions — statistically the same as in 2018.
- Just over a quarter (27%) of adults favor eliminating all private health insurance and making public insurance like Medicare the only coverage option. But 40 percent said they do not know enough to form an opinion.
- While a larger percentage of Democrats (43%) favored replacing all private insurance with a public plan compared to Republicans (12%) and independents (27%), 41 percent said they did not know enough to say.
- More than two-thirds (68%) of adults in states that have not yet expanded Medicaid favor expanding eligibility for the program. Majorities of Democrats (91%) and independents (74%) favor doing so, while Republicans are split, with 42 percent in favor and 48 percent opposed.
- Large majorities of insured adults are satisfied with their current coverage, with those enrolled in Medicaid and employer plans the most satisfied.
As of March–June 2019, 13.8 percent of adults ages 19 to 64 were uninsured. This estimate is not statistically different from uninsured rates in any year following the 2014 rollout of the ACA’s major expansions of coverage.3 It is also consistent with results of other surveys showing the uninsured rate holding steady or slightly increasing (see Uninsured Rate for U.S. Adults Compared to Other National Surveys Since 2013). Adults with low incomes, young adults, and Hispanics or Latinos — groups that made the greatest gains in coverage in the years following the coverage expansions — continue to have among the highest uninsured rates (Table 1).
This year is the first in which Americans no longer face a tax penalty for not having health insurance: Congress repealed the penalty, effective 2019. At the time of the survey, three states — Massachusetts New Jersey, and Vermont — as well as the District of Columbia had passed legislation establishing an individual mandate.4 Among survey respondents living outside these states, 54 percent were aware of the change in federal law, including 55 percent of insured adults and 48 percent of uninsured adults.
Among uninsured adults who were aware the penalty was no longer in effect, 24 percent said they chose not to get health insurance this year because of the change. This translates into about 11 percent of all uninsured adults.5
About 18 percent of U.S. adults shopped for health insurance in the ACA marketplaces in 2019. Of this group, by March–June, 26 percent reported having a marketplace plan. Another 18 percent had enrolled in Medicaid, and 26 percent had employer coverage; 18 percent were uninsured.6
We asked people who visited the marketplaces but didn’t end up enrolling in a plan or in Medicaid why they hadn’t. Half (51%) said the main reason was that they couldn’t find an affordable plan, while one-quarter (26%) had gotten insurance through another source. Four percent decided that they didn’t need health insurance. About one in five cited other reasons, such as their citizenship status or missing the enrollment deadline.
Several Democratic presidential candidates and members of Congress have proposed ways to increase insurance coverage and lower premiums and other health care costs.7 These range from raising the subsidies available for marketplace plans and covering uninsured people in states that haven’t expanded Medicaid, to replacing most insurance with a public program like Medicare.
When survey participants were asked about their views on a “Medicare for all”–type approach8 — specifically, one in which a public program like Medicare becomes the only health insurance option for everyone — just over a quarter (27%) of adults said they were in favor of it. But two in five adults (40%) said they did not know enough to say whether they favored or opposed such an approach.
While Democrats were the most strongly in favor of replacing all private insurance with a public plan, 41 percent indicated they needed more information to offer an opinion. Republicans were among the most strongly opposed to the proposal, with only 27 percent saying they didn’t know enough to say (Table 2). However, Republicans with lower incomes were much less likely to oppose the approach than were higher-income Republicans (41% v. 71%) (data not shown).
Seventeen states have not yet expanded eligibility for Medicaid, including two of the most populous states, Florida and Texas.9 An estimated 4.5 million people who would otherwise be eligible for Medicaid are uninsured in those states.10
We asked adults in states that have not expanded Medicaid whether they generally favored or opposed expanding eligibility. More than two-thirds (68%) of respondents in those states favored expansion. Majorities of Democrats (91%) and independents (74%) were in favor. Republicans were split, with 42 percent in favor and 48 percent opposed (Table 3).
Support for Medicaid expansion in these states was stronger among Republicans and independents with lower incomes. More than half (57%) of Republicans with incomes under 250 percent of the federal poverty level ($30,350 for an individual and $62,750 for a family of four) favored Medicaid expansion, compared to one-third (32%) of Republicans with incomes above that level. Among independents, 81 percent of those with lower incomes were in favor of expansion, compared to 66 percent of those with higher incomes. There was no difference in support by income among Democrats.
One of the key challenges faced by policymakers seeking to reform the health care system is that Americans who have health insurance are generally satisfied with it.
Large majorities of those we surveyed were either somewhat or very satisfied with their health insurance. Satisfaction was particularly high among people with Medicaid and employer coverage. An estimated 228 million people are enrolled in either insurance type.11
Satisfaction was lower among those with coverage purchased on the individual insurance market and marketplaces, an estimated 14 million people. However, there were significant differences by income. People with incomes under 250 percent of poverty, who pay less for their premiums and face lower cost-sharing, reported higher satisfaction with their coverage than those with higher incomes (84% vs. 65%) (Table 4). People with incomes at or above this level pay more, or all, of their premium and do not receive cost-sharing subsidies.
Despite people’s satisfaction with their current source of coverage, many lacked confidence about being able to afford their health care if they became seriously ill. Thirty-eight percent of all adults were either not too confident or not at all confident they would be able to afford their care. This included 29 percent of those with employer coverage, 39 percent of those with Medicaid, and 41 percent with individual-market plans. Uninsured adults expressed the greatest concern about the future: 72 percent were not too or not at all confident they would be able to afford their care if they became seriously ill.
Confidence was lower among people with lower income (Table 5). Nearly half (46%) of adults with incomes under 250 percent of poverty were not too or not at all confident in their ability to afford care if they were to become very sick.
After dropping significantly following the major coverage reforms in 2014, the U.S. uninsured rate has held steady or slightly increased, as our survey and others have shown. Four primary factors are at play:
- Many states have not expanded Medicaid eligibility.
- Premiums can be unaffordable for people with incomes just over the marketplace subsidy threshold ($48,560 for an individual or $100,400 for a family of four).
- Congress and the Trump administration have passed laws and taken executive actions on the ACA, such as repealing the individual mandate penalty and encouraging states to enact work requirements for Medicaid beneficiaries.
- Lack of access to subsidized coverage among undocumented immigrants.
This survey indicates that Congress’s repeal of the individual mandate penalty has had a small effect on people’s decisions to get health insurance this year, with about one in 10 uninsured adults opting not to get covered this year because of it. The Congressional Budget Office is projecting that about 7 million people will lack coverage because of the penalty repeal by 2021.12
Ongoing affordability concerns appear to play a more important role than the mandate penalty in people’s decisions to get coverage. In our survey, about half of adults who visited the marketplaces but did not enroll in a plan said they couldn’t find affordable coverage. Another recent survey found that affordability was the top reason why uninsured adults didn’t seek coverage through the marketplaces in the first place, and a top reason why adults with a coverage gap had dropped their individual-market plan.13
Medicaid has been a key component of the ACA’s coverage expansions, and enrollment in Medicaid is now higher than initially projected following the Supreme Court decision that made the expansion optional for states.14 Our survey indicates that nearly all those enrolled in Medicaid are satisfied with their insurance, and it also suggests that expansion has support among the general public. A majority of adults living in states that haven’t expanded Medicaid favor expansion, including a majority of Republicans with incomes under 250 percent of poverty.
Since the ACA’s passage in 2010, Congress has not passed legislation to get more people covered or to improve the affordability or cost-protection of private plans. Though many states have stepped up in multiple ways, it’s clear that improving coverage for all U.S. residents will require federal legislation. Several Democratic members of Congress and presidential candidates have introduced bills or put forth proposals to that end.15 These approaches are an amalgam of provisions that individually or collectively have the potential to make significant improvements in coverage.
Our survey indicates that much of the public currently needs more information before supporting a Medicare-for-all approach. Given the complexity of our health care system, this may also be the case regarding other approaches to improving coverage, including those advanced by Republicans. It may be up to the candidates to educate voters about what their proposals would mean for them and for the health care system, and what financing trade-offs might be required to achieve them.
How We Conducted This Study
The Commonwealth Fund Health Insurance in America Survey, March–June 2019 was conducted by SSRS from March 19 to June 9, 2019. The survey consisted of interviews conducted via web and telephone in English or Spanish among a random, nationally representative sample of 4,914 adults, ages 19 to 64, living in the United States. Overall, 1,453 interviews were completed via the online survey and 3,461 were completed via phone (either landline or mobile).
This survey is the eighth in a series of Commonwealth Fund surveys to track the implementation and impact of the Affordable Care Act (ACA). Prior waves were part of the Commonwealth Fund Affordable Care Act Tracking Survey. To see how the survey was conducted in prior waves, see here.
Unlike prior years, an address-based sample (ABS) was included in Wave 8. This change in sampling method and mode of response likely affected the trend on some measures between 2018 and 2019. However, the ABS sample was designed to mirror as closely as possible the RDD sampling approach used for the telephone sample.
As in all waves of the survey, the March–June 2019 sample was designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in Wave 8 were obtained through three sources: 1) a stratified RDD sample, using the same methodology as in Waves 1–7; 2) a stratified address-based sample of the population; and 3) households reached through the SSRS Omnibus where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. SSRS oversampled adults with incomes below 250 percent of poverty to further increase the likelihood of surveying respondents eligible for the coverage options as well as allow separate analyses of responses of low-income households. A comparable, stratified design was used for the address-based sample. The uninsured and those with Medicaid and marketplace insurance were oversampled more directly using numbers for individuals (cell sample) and households (landline sample) prescreened in the SSRS Omnibus in order to insure an adequate sample for questions on consumers’ experience using the marketplace, getting coverage under the ACA, and using their new coverage.
To counteract known biases inherent in ABS samples and to yield a more representative group of respondents, the ABS sample was disproportionately stratified to target addresses in areas with lower mean household incomes, as well as addresses in areas with high Hispanic incidence. The stratification was done at the Census Block Group level based on data available from the Census Planning Database. The ABS also included a separate listed low-income stratum.
Data were weighted to ensure the final outcome was representative of the adult population ages 19 to 64. The data are weighted to correct for oversampling uninsured, direct purchase and Medicaid respondents, the stratified sample design, the overlapping landline and cellular phone sample frames for the Omnibus prescreened completes, and disproportionate nonresponse that might bias results. In this wave’s sample design, the weights also corrected for oversampling respondents with a prepaid cell phone. The telephone and ABS samples were weighted separately to be representative of the target population on the following parameters: age, gender, race/ethnicity, education, geographic division, population density, and telephone use. All parameters were extracted from the U.S. Census Bureau’s 2017 American Community Survey data, with the exception of the telephone use benchmarks which was extracted from the latest available estimates from the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS).
The resulting weighted sample is representative of the approximately 190 million U.S. adults ages 19 to 64. Data for income, and subsequently for federal poverty level were imputed for cases with missing data utilizing a standard general linear model procedure. The survey has an overall margin of sampling error of +/– 1.9 percentage points at the 95 percent confidence level. The overall response rate, including the prescreened sample, was 7.6 percent.
The authors thank Robyn Rapoport, Sarah Glancey, Erin Czyzewicz, and Christian Kline of SSRS, and David Blumenthal, Elizabeth Fowler, Eric Schneider, Chris Hollander, Bethanne Fox, Deborah Lorber, Paul Frame, Jen Wilson, Gabriella Aboulafia, Corinne Lewis, and Jesse Baumgartner of the Commonwealth Fund.
1. Stephanie Armour, “American Voters Have a Simple Health-Care Message for 2020: Just Fix It!,” Wall Street Journal, updated June 2, 2019. and Monmouth University Polling Institute, “Iowa: Biden Holds Lead, Warren on the Chase,” Monmouth University, Aug. 8, 2019.
2. Edward R. Berchick, Jessica C. Barnett, and Rachel D. Upton, Health Insurance Coverage in the United States: 2018, Current Population Reports (U.S. Census Bureau, Sept. 2019); Robin A. Cohen, Emily P. Terlizzi, and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2018 (National Center for Health Statistics, May 2019); Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Commonwealth Fund, Feb. 2019); and Sara R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families (Commonwealth Fund, Dec. 2018).
3. The break in trend between 2018 and 2019 in the survey is not a statistically significant change. It may reflect, however, the change in sampling method and mode of response introduced into the survey in 2019.
4. At the time of the survey, the District of Columbia, Massachusetts, and New Jersey had mandate penalties in effect. Vermont passed an individual mandate effective in 2020, though it has yet to establish a penalty or other enforcement mechanism. California and Rhode Island have since passed individual mandate laws. See “What Is Your State Doing to Affect Access to Adequate Health Insurance?,” (Commonwealth Fund, updated Sept. 6, 2019).
5. This estimate is across all uninsured adults in our sample. There is no change when we remove uninsured adults who live in one of the four states that had passed individual mandate legislation.
6. In the “other” category, 5 percent of respondents were enrolled in Medicare, 4 percent in the individual market, and 3 percent cited other coverage.
7. Sara R. Collins and Roosa Tikkanen, “The Many Varieties of Universal Coverage,” Commonwealth Fund, updated Apr. 24, 2019; Sherry A. Glied and Jeanne M. Lambrew, “How Democratic Candidates for the Presidency in 2020 Could Choose Among Public Plans,” Health Affairs 37, no. 12 (Dec. 2018): 2084–91; and Sara R. Collins, Status of U.S. Health Insurance Coverage and the Potential of Recent Congressional Health Reform Bills to Expand Coverage and Lower Consumer Costs, Invited Testimony, U.S. House of Representatives Committee on Rules, Hearing on “Medicare for All Act of 2019,” Apr. 30, 2019.
8. We asked the question two different ways. Half the sample was asked, “Would you favor or oppose making public insurance like Medicare the only health insurance option for everyone, or do you not know enough about this to say?” Twenty-eight percent of respondents who were asked this question reported they were somewhat or strongly in favor, and 45 percent of respondents reported they do not know enough to say. The other half of the sample was asked, “Would you favor or oppose eliminating all private health insurance and making public insurance like Medicare the only health insurance option for everyone, or do you not know enough about this to say?” Twenty-seven percent of respondents who were asked this question reported they were somewhat or strongly in favor, and 40 percent reported they do not know enough to say. There was little to no difference in responses overall, or by demographics, including age, race/ethnicity, and political affiliation.
9. Voters approved ballots to expand eligibility for Medicaid in Idaho, Nebraska, and Utah in November 2018, but the states have yet to expand.
10. Rachel Garfield, Kendal Orgera, and Anthony Damico, The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid (Henry J. Kaiser Family Foundation, June 2018 and May 2019).
11. Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2019 to 2029 (CBO, May 2019).
12. CBO, Federal Subsidies, 2019.
13. Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do They Lack Coverage? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019).
14. After the Supreme Court decision that made Medicaid expansion a state option, CBO estimated that as of March 2015, Medicaid enrollment would increase by 10 million people. As of April 2019, Medicaid enrollment had increased by 15 million relative to the baseline. See Medicaid and CHIP Payment and Access Commission, “Medicaid Enrollment Changes Following the ACA,” MACPAC, May 2019. CBO estimates that in 2019, 12 million people had been made newly eligible because of the expansion.
15. Collins and Tikkanen, “Many Varieties,” 2019; Glied and Lambrew, “How Democratic Candidates,” 2018; and Collins, Status of U.S. Health, 2019.